(All Fields Are Required)
Patient Name
Patient Age
Your Email
Have you tested positive for COVID-19 in the past month? Or have you been advised by your physician or local public health department to self-isolate? YesNo
Do you have or have you recently had (in the past 14-21 days) any of the following symptoms:
Fever above (38°C) or feeling hot, chills/feverish? YesNo
Shortness of breath or other difficulties breathing? YesNo
Cough or worsening of a chronic cough? YesNo
Flu-like symptoms such as stomach upset, diarrhea, headache, fatigue or sore throat? YesNo
Recent alteration or loss of taste or smell? YesNo
Any new, unusual symptoms? e.g. feeling unwell, or sudden onset of runny nose? YesNo
Have you been in contact with anyone with confirmed COVID-19 or with any of the above symptoms of possible COVID-19 in the past 14 days? YesNo
Have you traveled in the past 14 days out of the country or to any COVID-19 hot spots? YesNo
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